'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

NICE sits on fence in BP controversy

NICE has awarded equal billing to calcium channel blockers and thiazide diuretics as first-line treatments for hypertension in its keenly anticipated final guidelines.

The radically overhauled guidance also erases ß-blockers from the list of first-line therapies, leaving GPs with a huge workload switching 1.6 million patients to alternative drugs.

The guidance, prepared in collaboration with the British Hypertension Society, sets out a brand new ACD algorithm for the treatment of hypertension.

Contrary to some media speculation, the institute has pulled back from plans to sideline diuretics as merely an 'alternative' to calcium channel blockers – after a furious response to its draft document.

Patients aged 55 or older and black patients of any age should now be started on 'a calcium channel blocker or a diuretic'. An ACE inhibitor, or if not tolerated an angiotensin receptor blocker, should be added as step two.

In the under-55s, ACE inhib-itors are first-line therapy.

Professor Bryan Williams, member of the guideline development group and professor of medicine at the University of Leicester, said around two million patients were currently taking ß-blockers for hypertension and most might now need switching.

'About 20 per cent maximum will have reasons to be on ß-blockers for reasons other than blood pressure. About 80 per cent you would anticipate could be changed at their next appointment.'

Professor Williams said GPs should use their clinical judgment to choose between calcium channel blockers or diuretics. 'If people are centrally obese or with impaired fasting glucose I would use a calcium channel blocker,' he added.

GP prescribing advisers were split in their reaction.

Dr Pravin Shah, CHD and diabetes lead for South Stoke PCT, criticised NICE.

He said: 'There should have been a clear choice for calcium channel blockers. If you use diuretics you are worried about diabetes.'

Dr George Kassianos, CHD lead at Bracknell Forest PCT, agreed: 'I think we have overwhelming evidence that the best drugs are ACE inhibitors and calcium channel blockers.'

But Dr John Ashcroft, CHD lead for Erewash PCT, said: 'As first-line it would still be a thiazide. More people get side-effects with calcium channel blockers.'

Professor Williams said the cost-differential between calcium channel blockers and diuretics was 'minimal'.